Zygomaticomaxillary (tripod) fracture

Background

• Must distinguish zygomaticomaxillary (tripod) fracture from zygomatic arch fracture
• Also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture
• Definition = fracture through:
  1. Inferior orbital rim
  2. Lateral orbital wall
  3. Zygomatic arch

Clinical Features

• Facial trauma (blunt, medially-directed force or high-energy decceleration)
• Normally depression of tripod (cheekbone) complex
• Lower eyelid/cheek pain, swelling, and ecchymosis
• +/- Diplopia with upward gaze (due to extraocular muscle contusion/entrapment, orbital hematoma)
• +/- Trismus
• +/- Epistaxis
• +/- Paresthesias of lower lid, cheek, nose, upper lip if injury to infraorbital nerve

Differential Diagnosis

Maxillofacial Trauma

• Ears
  • Auricular hematoma
• Nose
  • Nasal fracture
  • Nasal septal hematoma
• Oral
  • Dental trauma
  • Lip laceration
  • Tongue laceration
• Other face
  • Le Fort fractures
  • Mandible fracture
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Related
  • Head trauma (main)
    • Skull fracture
    • Skull fracture (peds)
    • Basilar skull fracture
  • Orbital trauma
    • Eyelid laceration
  • Scalp laceration

Evaluation

CT scan demonstrating a depressed zygomaticomaxillary complex fracture with loss of projection (top left), displacement at the sphenozygomatic suture (top right), zygomaticomaxillary buttress (bottom right), with minimal orbital floor displacement (bottom left).

Left zygomaticomaxillary complex fracture with associated orbital fracture.

• CT sinus/face
• Ocular exam to evaluate for concomitant orbital injury (e.g. retrobulbar hematoma, ruptured globe)

Management

• Analgesia
• Surgical consult
• Optho consult if ocular signs/symptoms
• Antibiotic prophylaxis if extends into paranasal sinuses (amoxicillin-clavulanate, doxycycline, or clindamycin)
  • For non-operative fractures into sinus, may not need prophylactic antibiotics
  • No difference in soft tissue infections in three groups (no prophylaxis, short course, long course)
• Usually requires surgical repair

Disposition

• Based on discussion with surgery
  • Generally may be discharged with outpatient surgical followup in 1 week

See Also

• Maxillofacial trauma